The current opioid epidemic is the deadliest drug crisis in U.S. history. In this edition of Blue Promise, we take a deeper dive to understand what caused the epidemic and just how addictive opioids are.

The current opioid epidemic is the deadliest drug crisis in U.S. history. In this edition of Blue Promise, we take a deeper dive into the epidemic to understand what caused it. We also talk about new research that may indicate the extent to which opioids are addictive. Leanne Metcalfe, PhD, Executive Director of Planning and Research, Phiyen Tra, PharmD, Director of Clinical Programs, and co-host Ross Blackstone, Director of Strategic Influence, join Dr. McCoy. You can listen to the complete discussion in podcast form on Apple Podcasts and SoundCloud.

Additional links in the Combating the Opioid Epidemic series:

Combating the Opioid Epidemic Part 1: Policymakers attempted to combat the opioid epidemic by placing regulations on the prescribing and dispensing of opioids. How well did those rules work? We discuss in this Blue Promise.

Combating the Opioid Epidemic Part 3: If current policies and procedures aren’t turning the tide against the opioid epidemic, what more should be done? We discuss what individuals and the public can do to help put an end to this crisis in this Blue Promise.

Blue Promise is an online video blog and podcast that aims to address complicated health issues with candid conversations from subject matter experts. New editions are published regularly and are hosted by Dr. Dan McCoy, President of Blue Cross and Blue Shield of Texas.

Drug overdoses primarily from opioids killed more people in 2016 than gun or car accidents and they're killing people at a pace faster than the

AIDS epidemic did at its peak so how did we get here?

Thanks for joining us for this edition of Blue Promise, I'm Dr. Dan McCoy and I'm here with Ross Blackstone.

ROSS:

And we have LeAnn Metcalf and Phyien Tra here to join us as well thanks for being here ladies so let's just kind of level set with everybody to make sure we're all on the same page and explain What are opioids?

I've heard some people kind of compare them to heroin. I've heard other people say maybe if I take too many over-the-counter pain medications that's kind of the same thing as an opioid or is it just anything that gets you high?

What is an opioid? you hear about it all over the news, Phiyen, define it for us.

PHIYEN:

Opioids actually are derived from the plant the poppy plant from opium and opium is basically a drug that has narcotic properties.

ROSS: So if you to many bagels with poppy seeds is that the same thing?

(Laughter)

PHIYEN:

No, not quite and since then there have been synthetic versions

of opioids that have been developed and the unique characteristic of all these drugs is that they bind to opioid receptors and basically these receptors help regulate pain but they also have an influence on your

body's perception of almost euphoria and it stimulates that type of excitability, which makes these drugs very…very addictive.

DAN:

Okay so do they all work the same, I mean, it's one opioid, are

they all equivalent?

PHIYEN:

No there are actually several different categories of opioids and different strengths and that's where morphine equivalent dosing comes in

where it's actually…

DAN:

So let's talk about that for just a minute, because what is morphine

equivalent dosing so explain that concept.

PHIYEN:

Morphine equivalent dosing is basically a way for prescribers to be

able to calculate doses and compare them to each other. It's the basically a scale that they use so that we can kind of equate one drug

to another based on how many equivalent doses.

DAN:

So give me an example, I would assume that morphine would be one morphine equivalent dose of..how would you..tell me an example. How…walk me through this.

PHIYEN:

Um so the comparison, there is a standard of comparison is morphine and so you can take codeine and compare it back to morphine and

I don't have the exact numbers…

DAN:

No it's okay

PHIYEN:

Basically it just shows you how strong that drug is in comparison to morphine.

DAN:

So where I'm gonna go here is that you don't need the numbers so where I'm gonna go here is that morphine is like a 1, we'll make that up right.

But these newer drugs are much larger dose?

PHIYEN:

Like pentanal.

DAN:

But give me an example, I mean relative terms, I mean these are

extremely more popularm I mean more powerful than you will than a

traditional morphine equivalent dose right

PHIYEN:

mm-hmm

DAN:

So what implications does that have?

PHIYEN:

Basically when you have a drug that's so much more powerful, there is a stronger likelihood of addiction developing because your body does become dependent on certain doses and stopping these medications actually precipitates withdrawal effects, so you have physiological effects once you stop these medications and a lot of times as we've been reading in the news this can lead to death.

DAN:

So, I guess the issue here is that patients might be thinking they're just taking one pill but the morphine equivalent dose of that pill could be significantly higher than that… that's the story? It’s sad actually..

ROSS:

It's very sad, in fact there were.. the number of people who died from opioids in Texas grew about three times between 1999 and 2014. So how did that become such an epidemic, Leanne? I mean people could get their high from anything but opioids they leaning there.

LEANNE:

You know when you look back through history, it's like a series of

good intended items and we go as far back as 1890 and you had this one

pharmaceutical company at the end of the different wars, it said hey we have this great idea. Let us bottle and sell this new pharmaceutical

called heroin and so 1890, they were selling this to help people with pain, that's really what they wanted to do help people who were in pain

then it was found out okay, this is addictive, we're gonna make this illegal. Flash forward a few more years, you develop different substances

on there with that framework of opioids and again to help people maybe avoid surgery you know. Okay you're in pain, we can have a surgical intervention or we can do this in the 1980s and you know this is regretful for me.

A bunch of researchers did some research on a small group of people and said Hey opioids are not addictive and so from there it allowed doctors

to write more prescriptions because this publication proved that these

medications weren't addictive.

ROSS:

So they were used in regulation

LEANNE:

Right and then you come to 2000 where we said Hey let's have pain be the fifth vital sign. We're gonna sit down. We're gonna ask questions.

DAN:

So wasn't that because to be honest in 2000 that was because we weren't doing a good job recognizing pain.

LEANNE:

Right we weren't so none of these things are bad things at no point in time did somebody go you know it's a good idea let's get everybody addicted to something you know. All of these were very well intentioned items and coupled with research saying that it was harmless essentially and let's figure out how much pain people are in. You couple all these

things together and you do create an epidemic.

ROSS:

That's when you get the question of what's your pain level, from a one to ten?

LEANNE:

Yeah

ROSS:

You know even your Mom might ask you that, it's good intentions.

LEANNE:

I know, make it a really nice chart, smiley face on one end and then you have this frowny ace on the other end and let me point to where you think you are and everyone's idea how much pain they're in is really relative

to them so I mean…

DAN:

I think it's fair to say that doctors and healthcare providers were judged by hospitals on how they were responding to addressing the pain concerns.

LEANNE:

Yeah Right

DAN:

And I assumed I think it's a fair statement, they addressed it with opioids.

LEANNE:

Yep Right

DAN:

And that was do you think that's a legitimate reason that there was an explosion in opioids after the introduction of that policy?

LEANNE:

Yeah you can definitely see within charts that there's a uptake in 2000

So there's a small uptake after the first research saying, hey, go ahead, they're safe. There's another uptake in 2000 and then there's another uptick in 2014 after the hydrocodone change from schedule 2 to schedule 3. So you have these policy implementations and then you see these the

unintended consequence being more opioid utilization.

DAN:

And I think the the other issue is the drugs have gotten stronger and more powerful.

LEANNE:

Yes.

ROSS:

So where are we today? I mean you hear about it in the news all the time, that background is helpful, What does it mean now Phiyen? Are more people addicted to opioids or is it a growing problem or is it starting to kind of get a little bit better because it's been in the news so much lately?

PHIYEN:

I think if you read the news and look at some statistics, recently there has been a decline in the number of opioid prescriptions written and so there is some progress that's being made in that sense. Probably through all the publicity that comes with the opioid epidemic and there's definitely still a lot of room for improvement. We definitely need more

collaboration between insurers, policymakers, prescribers and even the members and patients themselves are becoming more aware and knowledgeable about these issues.

DAN:

But certainly a big issue here is going to be to engage the provider community in addressing this problem.

PHIYEN:

Yeah.

DAN:

So I know that we have some emerging research here at Blue Cross about surgeries.

LEANNE:

Yes.

DAN:

Tell me a little bit about what you found, because I'm gonna be honest with you, I was shocked.

LEANNE:

We narrowed down, we looked at situations where someone would be in pain and have a surgical intervention to relieve that pain being, you know,

low back pain, spine surgeries, hip and knee replacements, so things

where people are probably in pain and then that's why they're doing that surgery and so we wanted to look at those individuals that weren't on opioids before that surgery and then how many were still in opiates,

30 days 90 days 365 days after the surgery and we found that over 30% of

people who were opioid naïve, so never in their history had taken an opioid or had filled an opioid script, were still on opioids a year after

their surgery, a year after this intervention that was supposed to reduce their pain.

DAN:

So one in three patients basically who had a procedure to help their pain were still on pain medications a year after.

LEANNE:

Yes.

DAN:

So, there's a lot of interpretations and clearly you need more study

but it kind of indicates a couple things, right?

Number one, the surgeries may not be that effective or the medications

are very addictive.

LEANNE:

Right.. yeah, yes

PHIYEN:

And here at Blue Cross, we have been identifying patients who are new to treatment and opioid naïve and basically working together to come up with ways to flag them early on and possibly put in some interventions to help them.

ROSS:

I read a study recently, Phiyen, that said sometimes opioids might not be any better than over-the-counter medications that you could just get at

in any you know drug store you're a pharmacist. What do you think?

PHIYEN:

Yeah and that definitely fits with the guidelines. A lot of times, prescribers should be using first-line therapies such as NSAIDs, ibuprofen, acetaminophen, Tylenol and then also an important factor that

plays into pain perception is rooted deeply in behavioral health and so a lot of times, you might have comorbid conditions such as depression that might actually exacerbate your pain and once you start seeking treatment for those types of conditions and can actually alleviate pain in different ways as well.

ROSS:

Okay, so we've talked a lot about the problem and something we've all talked about some of the research we're doing and some of the solutions that we're trying to put out there. There’s a whole lot more that we want to get to Dr. McCoy in our next segment and we also want to talk about the implications of opioids for our business and our business climate here in Texas and the economy as a whole.

DAN:

Well thanks for being here and I'm Dr. Dan McCoy. Thanks for joining us

Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Texas.

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